NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When caring for clients with Buck’s Traction, the major areas of importance should be:
- A. nutrition, elimination, comfort, safety
- B. ROM exercises, transportation
- C. nutrition, elimination, comfort, safety
- D. elimination, safety, isotonic exercises
Correct answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
2. When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?
- A. She will need to sign an informed consent form.
- B. Her mother or father will need to be contacted for permission to treat her.
- C. A consent form is not needed if the problem is a sexually transmitted infection.
- D. Anyone over the age of 18 years may sign a consent form for her treatment.
Correct answer: A
Rationale: Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.
3. Ethical and moral issues concerning restraints include all of the following except:
- A. emotional impact on the client and family
- B. dignity of the client
- C. client's quality of life
- D. policies and procedures
Correct answer: D
Rationale: The correct answer is 'policies and procedures.' While policies and procedures are important for guidance and structure, they do not inherently involve ethical or moral considerations. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all directly related to ethical and moral concerns when it comes to the use of restraints. These factors are crucial in ensuring that the use of restraints is not only physically necessary but also ethically justifiable and respects the individual's rights and well-being. Therefore, options A, B, and C are all aspects that touch upon ethical and moral dimensions in the context of restraints.
4. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills.
- B. contact with hot surfaces such as stoves and fireplaces.
- C. contact with flammable liquids or gases resulting in flash burns.
- D. sunburn from lack of protection and overexposure.
Correct answer: D
Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.
5. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?
- A. Open the airway.
- B. Administer oxygen.
- C. Suction the client.
- D. Check for breathing.
Correct answer: A
Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.
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